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Daily Dose

Asthma

1:30 to read

May is Asthma Awareness Month and I am certainly seeing many patients whose asthma and wheezing is getting the best of them right now. With all of the major weather changes across the country, pollen counts through the roof, and upper respiratory viruses still circulating, there are quite a few triggers to set off wheezing.

 

Asthma is a chronic lung disease and affects more than 6 million children in the United States. Asthma causes wheezing and chest tightness in some, while it may only cause nighttime cough and cough with exercise in others. There is not one single presentation to asthma and the diagnosis is best made with a good history and physical exam.  Although asthma is a chronic disease you may only have attacks when something is bothering your lungs (triggers).

 

The biggest challenge I see as a pediatrician is teaching both parents and children to recognize their triggers and to know what their medications are. Every patient should have an asthma action plan, but in some cases, a child may have only wheezed once..and their parents received an inhaler or a nebulizer but really does not know what to do if their child wheezes again.

 

If your child has wheezed before, and you have a family history of wheezing, your child has a greater chance of wheezing again.  You should have a discussion with your pediatrician about how to recognize wheezing in your child. At the same time, if you have ever received a medication for wheezing, make sure you know the name or names of the medication. I see many parents who come in to the office and they may have been seen at an ER or urgent care when they were noted to be wheezing. They received an “inhaler”, but the parent has no clue as to the name of the inhaler (they may say, “it is blue”), and they don’t understand how the medications work.

 

The two points I try to make with every patient I see with wheezing:  

#1  Know the names of the medications that you have

#2  Know what the medications do

 

There are two issues with asthma, lung inflammation and broncho spasm (narrowing of the airways). So…there are two medications commonly used to treat these issues.  Inhaled steroids (there are tons of brands) are used as a preventative and decrease inflammation, while albuterol (again tons of brands) is a broncho-dilator and opens up the narrowed airways.  I see too many patients that bring in a bag full of medications, from numerous doctors and still don’t understand what their medications are used for, when to use them and that several of their inhalers, while having different names, are actually the same medicine.

 

Lastly, children with divorced parents need to have inhalers available at both homes. I think it is too complicated to try and have parents hand the inhaler or medication back and forth and think they will not forget or lose the medication.  Ask your doctor to have meds for both houses.

Seeing that is is Asthma Awareness month, get your medications out and make sure that they are not expired and if you don’t understand how or when to use them, make an appointment with your pediatrician and get an asthma action plan in place. Be prepared!  

Daily Dose

Codeine & Children

1:30 to read

I order to keep us all safe, the FDA is constantly monitoring drugs and their side effects.  For many years codeine was prescribed for children for pain relief as well as to suppress coughs.  Over the last few years there has been more and more discussion about limiting the use of narcotics in children, but I continue to see some children who come from seeing other physicians and have received a prescription that contains codeine.

 

The FDA just issued new warnings against using prescription codeine in children and adolescents. The FDA reviewed adverse event reports from the past 50 years and found reports of severe breathing problems and 24 deaths linked to codeine in children and adolescents. Genetic variation in codeine metabolism may lead to excessive morphine levels in some children.

 

The FDA also performed a literature review which noted excessive sleepiness and breathing problems, including one death, in breast-fed infants whose mothers used codeine.

 

Due to these findings the FDA is now recommending that “codeine should not be used for pain or cough in children under 12 years of age”. They have also issued a warning that codeine should not be used in adolescents aged 12-18 “who are obese or have conditions associated with breathing problems, such as obstructive sleep apnea or severe lung disease”. In retrospect, codeine was prescribed to more than 800,000 children younger than11 years in 2011. Amazingly, codeine is currently available in over-the-counter cough medicines in 28 states.  

 

Lastly, the FDA “strengthened the warning” regarding codeine and breast feeding. They now recommend that breast- feeding women do not use codeine…which may change the post delivery pain protocol. Nonsteroidal anti-inflammatories (Ibuprofen) and acetaminophen (Tylenol) are preferred and are effective for mild to moderate postpartum pain. As a pediatrician it is important that I discuss this with new breast-feeding mothers as well. 

Daily Dose

How to Swallow a Pill

1:15 to read

I have always been a proponent of teaching children to swallow a pill.  In fact, I think I taught my boys to swallow a pill before they were 5 years old, mainly because I was tired of trying to find the measuring cup or syringe for the liquid medicine, which often didn’t go down “like spoon full of sugar”, even though we would sing the song during dosing. 

By the time one child had learned to swallow a pill the other two boys, as competitive as they were, decided that they too could do it, even the 2 year old.  So, based on that experience I have been encouraging young patients to swallow pills, and even teaching them in the office with my stash of mini M&M’s and Tic Tacs!  I also know that if you wait too long it becomes a huge ISSUE.

Well, who knew that someone would actually study “pediatric pill swallowing”?  In an article just published in the May issue of Pediatrics the authors looked at different pill swallowing interventions.  They found that up to 50 % of children were unable to swallow a pill.   Problems swallowing pills included a variety of reasons including fear, anxiety and intolerance to unpleasant flavors. 

The authors reviewed 5 articles published since 1987 which found that behavioral therapy, flavored throat sprays, specialized pill cups and verbal instruction with correct head and tongue positioning all helped children to swallow pills. They also found that pill swallowing training as “young as 2 years helped increase the likelihood of ease of pill swallowing”.

So, like many things....jump in with your young child and master the art of pill swallowing sooner than later. It will make everyone’s life easier.

Last caveat, I always tell my patients who are older “non-pill” swallowers, “you cannot possibly operate a motor vehicle if you can’t swallow a pill”! This is usually a huge motivator for the “late swallower” and they conquer the challenge. 

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Daily Dose

Teaching Kids How To Swallow A Pill

Teach your child how to swallow a pillLife would be a bit easier (when your child is sick) if your child knew how to swallow a pill.

I am continually reminded about the number of kids and teens that don't swallow pills, and ask, "does that medication come as a liquid?" Even some of my "adult" patients (code for friends over 40) call and ask if their cholesterol lowering medication is available as a liquid as they just can't swallow a pill! These are people that can run companies! So...due to that fact, I am convinced, like many things in life, the younger you learn to do something, the easier it is. The old adage, "can't teach an old dog new tricks" is true, young children are excited about trying new things and accomplishing milestones, so put pill swallowing on the list.

I started teaching my own children how to swallow pills when they were around four-years-old. It really came out of necessity when we were on a trip and one of them developed a fever and I did not have any liquid Tylenol with me. Being the novice "parent pediatrician" at the time, I thought I could just "push the pill down their throat", like the dog. Guess what? It doesn't work, as they just gagged and threw up all over me! Lesson learned. I have found the best way to teach a younger child to swallow a pill is to make it a game. I took the boys to the nearest 7-Eleven where we bought their favorite tic-tacs (coated on the outside like a caplet so won't stick) and then let them pick their favorite sugary horrible never allowed drink. I think it was a Coke or 7-Up at the time (forbidden fruit at home). We went home with candy and drinks in hand (mini M&M’s also work well) and began the tutorial. It helps to have a little friendly competition too. Show your child how to put the tic-tac on the back of their tongue (not on the tip) and then have them "GUZZLE" the drink.  That is why you need to use their favorite drink so they really want to drink it robustly. You can't learn to swallow a pill with a small amount of liquid, you need a "big gulp" to wash it down. When kids are younger they usually don't worry about "choking" or gagging, but once they are older they start analyzing and worrying about how the pill will get stuck or gag them and their anxiety gets in the way. Look at it like going down a slide for the first time, or jumping into the pool, younger kids are usually less fearful (not always a good thing). For many children it will take several tries before the tic-tac is miraculously washed down!! They are so proud and excited and want to show you that they can do it again and again (therefore practice with candy and NOT real medication). By the time they are really becoming proficient they will often say, "look, I can do three at a time!!). Once they are swallowing it is very easy to use junior strength Tylenol or Motrin, which are smaller and coated. Again, once they are swallowing pills the size of the pill really doesn't matter as they all "wash down" the same way. I use the analogy of learning to ride a bike, once you can do a two-wheeler, you can probably ride your friends bike that may have a little bigger tires, if need be. They all pedal the same way and require balance. Pills are pills, just pop and swallow! I also jokingly tell all of my young patients that it is "Dr. Sue rule" that they are able to swallow a pill before they can drive a car!! Come on, putting a teen behind the wheel of a car is HUGE, and swallowing a pill seems much easier compared to learning to drive. I must say that the majority of my patients can swallow a pill by early elementary school, and many even younger. Learning to swallow a pill is a right of passage during childhood. Make it fun and cross this off of the "to do list"! That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Why You Should Read Labels

With the cold season in full swing there is yet another story about an over-the-counter product being used in a child under the age of two. In this case, the product was not ingested, but applied topically. That product is Vicks VapoRub, which was the "gold standard" in my home for treating a chest cold (at least that is what it was called by my mother). I can recall that blue glass jar being on the counter in our bedrooms and having it rubbed on my chest and then having a warm washcloth placed over it. To this day I love the smell of Vicks.

But this recent study in Chest discusses the case of an 18-month-old who developed significant respiratory distress after having Vicks applied beneath her nose to relieve her cold symptoms. It seems that Vicks (and one would surmise other similar products) acts as an airway irritant, which in turn may actually cause more mucous production and subsequent respiratory distress, especially in children who have smaller airways than adults. I was impressed that the doctors at Wake Forest put 2 + 2 together and hypothesized that the Vicks was the culprit. Then these doctors went to the animal model, in this case a ferret, to see if they could cause respiratory distress in these animals (who is seems have airways similar to a child's) by applying Vicks to their noses. Indeed, the ferrets developed respiratory distress. In all fairness to Vicks, it does state on the bottle, "Do not put beneath the nose" and "Do not use in children under two". Again, parents need to continue to be conscientious and read labels. This article also does not state if the family used an entire bottle of Vicks, or was it repetitive use etc. Regardless, the take home message is: Read labels, do not use OTC products in children under the age of six, and the best cure for colds is a cool mist humidifier in the room, lots of fluids and salt water nose drops to clear the little nostrils. That's your daily dose, we'll chat again tomorrow.

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Daily Dose

Treating the Common Cold

Having a cold myself is a sobering reminder that the average cold lasts seven - 10 days and the cough may last up to two to three weeks.I have had this nasty fall cold for the last week, and I gotta say, " I am sick of it!" I am not really surprised that I finally succumbed to my first cold of the season. While I am seeing 20 -30 kids a day with colds, it's not hard to figure out why my own body just waved the white flag and joined the ranks of cold sufferers. But having a cold myself is a sobering reminder that the average cold lasts seven - 10 days and the cough may last up to two to three weeks. That being said, I still have a week to go and I just want to hibernate until it is gone. Unfortunately, that is not reality for most of us.

My sweet patients are always concerned about my health, and then wonder, "What do you do for your cold, Dr. Sue?" That just makes me giggle, as I know they have heard me say a million times, "there is really not much to do for a cold except rest, fluids, throat lozenges, and tincture of time." I wish I had been hiding the secret potion that only doctors can take to make their colds go away in a day. So for the last week I have sucked on any lozenge that people hand me (I personally think lemon helps the most), have had enough hot tea to float a boat, and really tried to get to bed at a reasonable hour, right after that warm bath with eucalyptus oil. Guess what? My cold is still here. If anyone else has the recipe for that "secret cold potion" I am open to suggestions, but figure at least I am half way through it and hope it will stay away until the spring? In the meantime, I am still washing my hands. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Vapor Rubs: Do They Really Work?

1:15 to read

There was a great article recently published in the online journal of Pediatrics.  I had to read it as it was titled, “Vapor Rub, Petrolatum, or No Treatment for Nocturnal Cough”.  Having been a fan of both Vick’s Vapor Rub and Mentholatum since I was a child, I knew it was a MUST read article.

You can ask all of my family members, once we hit cough and cold season, the “vapor rub” jar goes next to my bed to help me during my frequent colds (see previous posts!).  I have such fond memories of being with my grandmother, Gaga, who at the first sign of a cold,  would rub Vicks all over my chest, which was then occluded by a warm damp CLEAN dishtowel, then followed by my flannel nightgown.  She would lovingly tuck me into bed, and shut the door and the whole room smelled like camphor, and menthol.   To me it was wonderful, my brother hated it!! As I grew older, my mother would hear me sniffle or blow my nose and down the hall she would come with the trusty Vick’s jar for self-application. Once I became a mother, in the family tradition, I too would rub a little Vick’s on my children’s chest, with no basis on medical fact, only what Gaga did. Funny thing, we all seemed to get better.

Two of my own children grew to despise the tradition, while one still asks for Vick’s or Mentholatum when he gets a cold.  There are old jars all over the house. I even bought several of the “plug ins” to use during cold season, which are the new fangled way to get that wonderful VR aroma into the room. They make a great stocking stuffer! So, with that history, what could be better than a study out of Penn State University that looked at the use of vapor rub (VR) to improve cold symptoms and nighttime cough.  With the recent FDA guidelines which limit the use of OTC cough and cold products in young children, many parents are at a loss as to what to do to help their child’s cold symptoms. The investigators looked at 138 children between the ages of 2 – 11 years. They were randomized to receive vapor rub (VR), petrolatum alone or no therapy.  Parents were then asked to grade their child’s symptoms and sleep on Day 1 when none of the children received therapy, and then again on Day 2 when they were randomized to therapy. 

The VR group scored best in improving cough, congestion and overall sleep for the children (and therefore their parents). This is the first evidence based therapeutic trial that I am aware of, for a remedy that is over a century old. As noted in the article, there were some irritant effects seen in the VR group with complaints of a stinging sensation to eyes, nose and or skin (I can hear my own children saying “it’s stingy”). Most of these complaints were transient in nature.  Despite older concerns about camphor when it was used as an oil that could cause possible toxicity if swallowed, skin exposure alone really has little systemic effect.   The FDA has approved camphor as an effective anti-cough preparation (anti-tusssive), but has limited concentrations to 11%. The concentration in VR is 4.8%. So, if parent’s are trying to improve nighttime cough and sleep disturbance in their children over the age of 2, there is a study to show it is time to go back to vapor rub preparations.  The mechanism for improved sleep is not really known, but whether it improves cold symptoms directly or through the aromatic effects, a better night’s sleep is good for everyone!!!  Could there be coupons to follow?

That's your daily dose for today.  We'll chat again tomorrow. Send your question or comment to Dr. Sue!

Your Teen

Acetaminophen, No Threat To Child's Liver

2.00 to read

With more than eight million American kids taking the drug every week, acetaminophen is the nation's most popular drug in children. It's toxic to the liver in high doses, and can be fatal if taken in excess. Very rarely, adults may also get liver damage at normal doses, so doctors had worried if the same was true for kids. Concerns about liver injuries in children who take the common painkiller acetaminophen, sold as Tylenol in the U.S. are unfounded, researchers said on Monday. "None of the 32,000 children in this study were reported to have symptoms of obvious liver disease," said Dr. Eric Lavonas of the Rocky Mountain Poison and Drug Center in Denver. "The only hint of harm we found was some lab abnormalities." With more than eight million American kids taking the drug every week, acetaminophen is the nation's most popular drug in children. It's toxic to the liver in high doses, and can be fatal if taken in excess. Very rarely, adults may also get liver damage at normal doses, so doctors had worried if the same was true for kids. "This drug is used so commonly that even a very rare safety concern is a big concern," said Lavonas, whose findings appear in the journal Pediatrics. Some researchers suspect there is a link between long-term use of acetaminophen and the global rise in asthma and allergies, but the evidence is far from clear at this point. For the new report, researchers pooled earlier studies that followed kids who had been given acetaminophen for at least 24 hours. There were no reports of liver injuries leading to symptoms such as stomachache, nausea or vomiting, in the 62 reports they found. Ten kids, or about three in 10,000, had high levels of liver enzymes in their blood, which usually means their livers have been damaged. In most cases, however, those elevations were unrelated to acetaminophen. And even if they were caused by the drug, they don't indicate lasting damage, according to Lavonas. "Acetaminophen is extremely safe for children when given correctly," he said. "Parents should not be afraid to give acetaminophen to their children when they need it, but they should be very careful about giving the right dose." "If you suspect that you have given a child an overdose, call your state's poison center," he added. The Rocky Mountain Poison and Drug Center receives funding from McNeil Consumer Healthcare, the Johnson & Johnson subsidiary that sells Tylenol, but the researchers said the company did not support this study.

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